The Journal of Emergency Medicine

Editorial Board

2012-01-01

Risk Factors Associated with Delayed Diagnosis of Acute Pulmonary Embolism

Sean B. Smith, Jeffrey B. Geske, Timothy I. Morgenthaler — 2011-09-28

Abstract: Background: Prompt diagnosis and treatment of acute pulmonary embolism (PE) is essential to reduce mortality. Risk factors for PE are well known, but factors associated with delayed diagnosis are less clear.Objective: Our objective was to identify clinical factors associated with delayed diagnosis of patients with acute PE presenting to a tertiary-care emergency department (ED).Methods: We studied 400 consecutive adults who presented to our ED with acute, symptomatic PE. All patients were diagnosed by computed tomography (CT) angiography. Early diagnosis was defined as CT diagnosis<12h from ED arrival, and delayed diagnosis as CT diagnosis>12h. Univariate and multiple logistic regression models were used to identify factors associated with delayed diagnosis. Odds ratios with 95% confidence intervals are reported.Results: The median time from arrival to diagnosis was 2.4h (interquartile range 1.4–7.6), and 73 (18.3%) patients had delayed diagnosis. Patients aged>65 years and those with coronary artery disease or congestive heart failure had longer times from ED arrival to CT diagnosis, whereas patients with recent immobility had shorter times. Patients diagnosed>12h were older and had higher rates of morbid obesity and coronary artery disease, whereas patients diagnosed<12h had higher rates of tachycardia. In multiple regression modeling, tachycardia and recent immobility remained associated with early diagnosis, whereas morbid obesity remained associated with delayed diagnosis.Conclusions: Older patients with cardiovascular comorbidities had longer times from ED arrival to CT diagnosis. Our data suggest that these patients represent more of a diagnostic challenge than those presenting with traditional risk factors for PE, such as tachycardia and recent immobilization. Physicians should consider these factors to diagnosis acute PE promptly in the ED.

Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

2009-10-15

Abstract: Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.

Quantifying Drug-seeking Behavior: A Case Control Study

Casey A. Grover, Reb J.H. Close, Erik D. Wiele, Kathy Villarreal, Lee M. Goldman — 2011-09-28

Abstract: Background: Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence.Study Objectives: To perform a case-control study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients.Methods: We performed a retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a non-narcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain.Results: The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors.Conclusions: Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.

Malpractice Claims on Emergency Physicians: Time and Money

Darien Cohen, Shu B. Chan, Marc Dorfman — 2008-12-08

Abstract: Background: Emergency medicine, with its limited time for patient encounters, unpredictable flow, and lack of a continuing patient-physician relationship, is a particularly high-risk field with regards to the issue of medical liability. There have been limited studies on the financial and time exposure emergency physicians face when confronted with a liability suit. Objectives: Provide practicing physicians with guidance as to what can be expected if they are confronted with a medical malpractice claim, and contribute to the literature as the issue of tort reform is debated. Methods: Retrospective study of all closed malpractice claims involving emergency physicians insured by the Illinois State Medical Inter-insurance Exchange covering the 10-year period 1995 to 2004. Results: Of 450 claims, there were 200 cases served. The median incident-to-close time was 45.5 months (interquartile range [IQR] 30.6–69.9). The median expense per claim served was $14,091 (IQR $3448–$44,363); 19.5% of cases resulted in an indemnity with a median of $220,000 (IQR $117,500–$700,000). Cases in which an indemnity was eventually made tended to be filed 7.7 months faster (p = 0.065) and took 14.1 months longer to close (p < 0.05). In cases with a payout of ≥ $1,000,000, 80% were in the ≤ 1-year age group. Conclusion: In this study, emergency physicians with malpractice suits can expect resolution of the case to take over 45 months after an alleged incident, and their malpractice insurer will incur over $14,000 in expenses regardless of the suit outcome. Cases involving patients aged ≤ 1 year may incur higher indemnity payments.

Effective Myocardial Salvage with Percutaneous Coronary Intervention in Late Diagnosed Acute Post-Traumatic ST-Elevation Myocardial Infarction

2008-12-08

Abstract: Background: Acute post-traumatic ST-elevation myocardial infarction (STEMI) is rare but potentially disastrous in patients with blunt cardiac injury. Sometimes the diagnosis is delayed. Failed myocardial salvage by percutaneous coronary intervention (PCI) within 9 h after the onset of post-traumatic STEMI has been described. Objective: We present a case report of a patient in whom effective myocardial salvage with PCI was obtained in a late diagnosed acute post-traumatic STEMI. Case Report: We report the case of a young man who was involved in a motorcycle crash, who had a delayed diagnosis of post-traumatic STEMI. Diagnostic coronary angiography was performed to guide treatment strategy. An occluded left anterior descending artery due to a dissection, and an intimal flap at the first diagonal branch were found. A PCI was done 18 h after the onset of the event with striking and immediate improvement of the regional left ventricular wall motion and ejection fraction. Conclusion: After blunt thoracic injury, there is the possibility of an acute post-traumatic STEMI being present when facing a patient with clues of blunt cardiac injury. If the diagnosis of acute post-traumatic STEMI is clinically strong, the patient should be managed individually according to the clinical scenario. Early recognition and prompt management are vital when dealing with patients suffering post-traumatic STEMI.

Window of Opportunity: Flexion Myelopathy After Drug Overdose

Allen S. Nielsen, Denise M. Damek — 2008-12-12

Abstract: Background: Cervical and thoracic flexion myelopathy are uncommon causes of spinal cord injury that can lead to irreversible paralysis, autonomic dysfunction, and death. To the authors' knowledge, this report is the first to describe the natural history of flexion myelopathy and the simultaneous occurrence of cervical and thoracic flexion myelopathy in the setting of drug overdose. Objectives: To report the association of cervical and thoracic flexion myelopathy and drug overdose; to describe the subacute natural history of flexion myelopathy in the setting of drug overdose; to emphasize the need for first responders to document positioning of unresponsive individuals; and to suggest careful neurological examination and early spinal cord imaging in appropriately identified patients at risk of flexion myelopathy. Case Report: We describe the case of a 34-year-old woman who developed flexion myelopathy resulting in severe quadriparesis after overdose of quetiapine fumarate, oxycodone/acetaminophen, and chloral hydrate. Conclusion: Flexion myelopathy in the setting of drug overdose is a subacute injury. Early intervention may limit neurological disability. However, the clinical diagnosis of flexion myelopathy is inevitably delayed by the patient's altered level of consciousness or mental status at presentation, and concurrent multiple organ failure.

Use of Emergency Department Transcranial Doppler Assessment of Reperfusion After Intravenous tPA for Ischemic Stroke

2008-12-29

Abstract: Background: Thrombolysis with intravenous recombinant tissue plasminogen activator (IV-tPA) has been associated with significant improvements in clinical outcomes when initiated within 3 h of symptom onset. Although adjunctive therapies for acute stroke have been developed, challenges remain in identifying appropriate patients and therapeutic end-point measurements. Objective: To describe the use of transcranial Doppler (TCD) monitoring in the Emergency Department (ED) to guide the decision for advanced reperfusion strategies after failure of IV-tPA. Case Report: A 75-year-old man presented to the ED within 50 min after the acute onset of right-sided hemiparesis and aphasia. After administration of IV-tPA, there was no immediate improvement in neurological symptoms. TCD performed in the ED demonstrated persistent left middle cerebral artery (MCA) occlusion. Based on this information, the patient received intra-arterial tPA followed by mechanical thrombectomy of the MCA occlusion, resulting in clinical improvement of the patient's right hemiparesis and aphasia. Conclusion: TCD is a feasible assessment tool for use in the ED to aid in diagnosis and to guide treatment decisions in patients with acute ischemic stroke, including those not responding to IV-tPA therapy.

Treatment of Laryngeal Hereditary Angioedema

Mark J. Richman, David A. Talan, William R. Lumry — 2011-02-14

Abstract: Background: In the emergency department, patients with laryngeal swelling and an inconclusive patient history may receive treatment for allergy-mediated angioedema. Intubation may be necessary if the patient does not respond to treatment. Because angioedema subtypes respond to different interventions, a correct diagnosis is vital.Objectives: Review the differential diagnosis of angioedema and characteristics differentiating subtypes. Discuss therapies for angioedema subtypes. Introduce therapies for prevention and acute treatment of hereditary angioedema (HAE).Case Report: A 10-year-old girl presented with laryngeal swelling unresponsive to diphenhydramine, methylprednisolone, and epinephrine. It was later revealed that she had a family history of HAE, was C1 inhibitor deficient, and enrolled in a clinical study of acute HAE treatment. She was given 1000 units of nanofiltered C1 inhibitor and was able to swallow within 30 min. She was prescribed routine prophylaxis with C1 inhibitor concentrate and has had no subsequent severe HAE swelling attacks.Conclusion: This case illustrates the need for providers to consider HAE in light of available diagnostic testing and recent Food and Drug Administration approval of specific therapies for HAE.

Lipid Emulsion as Rescue Therapy in Lamotrigine Overdose

2011-05-30

Abstract: Background: Lamotrigine is a sodium channel blocking agent that is widely prescribed for treatment of seizure. Although life-threatening effects are rarely observed in overdose, some previous reports have described the occurrence of cardiac toxicity. The management of sodium channel blocking agent-induced cardiotoxicity conventionally requires sodium bicarbonate administration. Recent case reports describe intravenous lipid administration as a successful treatment for refractory cardiovascular collapse induced by sodium channel blocking medications.Objective: The objective of this study is to report the use of intravenous lipid emulsion as adjunctive therapy in a case of lamotrigine overdose in which electrocardiographic changes were unresponsive to bicarbonate therapy.Case Report: We report a case of intentional lamotrigine overdose in a 50-year-old woman who lost consciousness and developed electrocardiographic aberrations, including widening of QRS with occurrence of left bundle branch block. The patient was initially treated with sodium bicarbonate without effect. Recovery of cardiac conduction was rapidly achieved after infusion of a 20% lipid emulsion. The exact mechanism of action of lipid emulsion is not fully understood. The lipophilic properties of lamotrigine suggest that it was partially removed by the plasmatic lipid emulsion.Conclusion: This case provides additional insight into the potential benefit of using lipid emulsion in refractory sodium channel blocking intoxications.

Accuracy of Microscopic Urine Analysis and Chest Radiography in Patients with Severe Sepsis and Septic Shock

Roberta Capp, Yuchiao Chang, David F.M. Brown — 2011-01-10

Abstract: Background: Diagnosis of source of infection in patients with septic shock and severe sepsis needs to be done rapidly and accurately to guide appropriate antibiotic therapy.Objective: The purpose of this study is to evaluate the accuracy of two diagnostic studies used in the emergency department (ED) to guide diagnosis of source of infection in this patient population.Methods: This was a retrospective review of ED patients admitted to an intensive care unit with the diagnosis of severe sepsis or septic shock over a 12-month period. We evaluated accuracy of initial microscopic urine analysis testing and chest radiography in the diagnosis of urinary tract infections and pneumonia, respectively.Results: Of the 1400 patients admitted to intensive care units, 170 patients met criteria for severe sepsis and septic shock. There were a total of 47 patients diagnosed with urinary tract infection, and their initial microscopic urine analysis with counts>10 white blood cells were 80% sensitive (95% confidence interval [CI] .66–.90) and 66% specific (95% CI .52–.77) for the positive final urine culture result. There were 85 patients with final diagnosis of pneumonia. The sensitivity and specificity of initial chest radiography were, respectively, 58% (95% CI .46–.68) and 91% (95% CI .81–.95) for the diagnosis of pneumonia.Conclusion: In patients with severe sepsis and septic shock, the chest radiograph has low sensitivity of 58%, whereas urine analysis has a low specificity of 66%. Given the importance of appropriate antibiotic selection and optimal but not perfect test characteristics, this population may benefit from broad-spectrum antibiotics, rather than antibiotics tailored toward a particular source of infection.

Massive Pneumoperitoneum After Colonoscopy

2009-10-15

A 79-year-old woman was sent to the Emergency Department with intense abdominal pain after diagnostic colonoscopy. Examination revealed marked abdominal distension with intense pain on both flanks. Post-colonoscopy complication was suspected, and plain radiographs were taken with the patient in decubitus position because she was too weak to assume other positions. The abdominal radiograph () revealed the football sign, the Rigler sign (with several intestinal loops clearly visible as a result of the colonoscopy), and the telltale triangle sign. These data were indicative of massive pneumoperitoneum. The chest radiograph () revealed extensive hyperlucency on the hepatic parenchyma, and the ligamentum teres was clearly visible. The patient underwent surgery, which revealed a perforation 5 cm in length on the anterior aspect of the sigmoid colon. Repair was by primary suture.

“Cord Sign” in Deep Cerebral Venous Thrombosis

2010-01-04

A 17-month-old girl presented to the emergency department (ED) with an altered sensorium and abnormal limb movements that had developed over the prior 6 h. She had a history of vomiting (non-bilious and non-projectile), lethargy, and poor feeding for the prior 7 days. Neurological examination showed exaggerated limb reflexes, however, tone and power were normal. A non-contrast head computed tomography (CT) scan () showed ill-defined hypodensities in both thalami, with hyperdensity in the internal cerebral vein, vein of Galen, and straight sinus, suggestive of deep cerebral venous thrombosis (DCVT).

Ulcers in the Eye

Daniel Morris, Emi Latham — 2009-09-18

Corneal ulcerations are a common finding in patients presenting to the Emergency Department (ED) with a painful irritated eye. There are numerous etiologies for corneal ulcers, and differentiating between these etiologies can alter the management of the patient. We will discuss the diagnoses in two cases of corneal ulceration that presented to the ED with unilateral painful red eye. The appearance of the face and neurologic examinations were the same for both patients, and the important distinctions between the 2 patients were possible only on the slit lamp examination. Based on the results of the ED slit lamp examination, the patients were diagnosed with different etiologies for their corneal ulcers and were treated as indicated.

Maisonneuve Fracture Sometimes Needs Stress View

Rafid Kakel — 2010-03-02

In the article titled “Maisonneuve Fracture” by Millen and Lindberg, which appeared in The Journal of Emergency Medicine, January 2009, it states: “An intact mortise with no joint space widening can be treated by casting and follow-up with Orthopedics in 6–8 weeks. A mortise that is not in anatomic alignment requires open reduction” ().

Prevention and Sporadic Carbon Monoxide Poisoning Related to Shisha (Hookah, Narghile) Tobacco Smoking

Kamal Chaouachi — 2010-02-05

Fortunately, carbon monoxide (CO) poisoning due to shisha (hookah, narghile) smoking is rather rare, and, when it happens here and there, it is due to the absence, for more than 10 years, of a modern tobacco harm reduction preventive educational program. We would like to inform Uyanik and his team of two other reported cases in the world (). The first was described by Lim et al. in Singapore and the other in France, a country known for having, as of 2 years ago, a total of about one thousand neo-orientalist narghile smoking tea houses (). The main source of the high registered CO levels is the charcoal used to heat the smoking mixture at the top of the pipe. Traditionally, in Asia and Africa, smoking takes place in the open air or in well-ventilated venues. Indeed, Eastern and European cafes are very different in this respect. Most of the time, the sporadic poisonings are due to the absence of efficient ventilation where hookah, generally with cigarette, smoking is performed. Unfortunately, public health prevention messages clearly mentioning the CO hazards related to hookah smoking have never been issued. Interventions have unsuccessfully been targeting eradication of use (). Notably, reported COHb concentrations from hookah smoking generally range between 20% and 30%: Uyanik et al. report 28.7%; Lim et al. and Levant et al. reported 27.8% and 20.8%, respectively ().

Drowning Terminology

Seth C. Hawkins, Justin Sempsrott — 2011-10-07

We read with interest Muth et al.’s study, “Infrared Ear Thermometry in Water-related Accidents—Not a Good Choice,” and applaud their contribution to the literature of drowning management ().

Ehrmann Response to Hawkins and Sempsrott

Ulrich Ehrmann, Claus-Martin Muth, Erik Shank — 2011-05-16

In response to the letter of colleagues Hawkins and Sempsrott, we totally agree that in future articles on drowning, only the new terminology should be used. We are aware of the World Congress on Drowning 2002 in Amsterdam, and recognize that a change in the terminology of drowning accidents was proposed. In the following years there was a debate on this, and both terms were used during that time.

Blunt Trauma Patients Require a Pelvic Stability Examination

Scott D. Weingart — 2010-02-01

A study from the trauma literature was recently abstracted in the Journal of Emergency Medicine by Dr. Krier, with a Comment after the abstract (Editor's Note: the Comments to abstracts are written by the Section Editor of the Abstracts section, Jeffrey Sankoff, MD). The Comment concluded that the pelvic examination before the radiology evaluation may not be helpful in patients with pain, tenderness, or poor mental status (). The primary reason to perform a pelvic ring stability examination in a blunt trauma patient is to assess for the need for pelvic reduction. Each blunt trauma patient should have a single examination by an experienced provider. The examination should consist solely of inward pressure toward the midline with hands placed on the anterior superior iliac spine. If the pelvis moves under the examiner's hands, pressure should be maintained and a bed sheet should be tied around the patient's greater trochanters. Alternatively, a commercial pelvic binder can be applied (). This maneuver will reduce venous bleeding into the retroperitoneum and should be undertaken as soon as possible in an open book pelvic fracture. The number of patients in this abstracted study with unstable open book pelvic fractures (Tile Class B1) was only 8, making the precision of sensitivity or specificity in this particular group poor, though the specificity in unstable fractures in general was high (99%) (). Waiting for radiologic evaluation in this patient group can lead to continued hemorrhage and progression of the lethal triad.

Further Confirmation of the Role of Clinical Acumen in Suspected Pulmonary Embolism

Oscar M.P. Jolobe — 2010-01-25

The outcome in the reported case of pulmonary embolism despite negative enzyme-linked immunosorbent assay D-dimer is a vindication of the role of clinical acumen in clinical decision-making (). Even in protocol-driven studies, there remains an important role for those clinicians who, in violation of the prescribed protocol, have sufficient courage of their convictions to give expression to their own clinical acumen. Such was the case in a prospective diagnostic management study that enrolled patients with clinically suspected pulmonary embolism (PE) in several hospitals in the Netherlands (). According to the protocol, where “the combination of PE being unlikely and a normal D-dimer test result ruled out PE,” both spiral computed tomography (CT) scanning and anticoagulant therapy were withheld. In that study, D-dimer test results and completed clinical probability assessments (using the criteria of Wells et al.) were available in 1632 patients (). Among those 1632 patients, there were 477 with the combination of unlikely clinical probability of PE and normal D-dimer, and in whom the protocol, by definition, mandated withholding spiral CT scanning. Nevertheless, in 2 of those patients, in violation of the protocol, the attending physician requested spiral CT scanning at baseline, and this investigation validated the clinical suspicion of PE. In 3 other patients with unlikely clinical probability of PE and negative D-dimer, PE occurred during the follow-up period. Among 86 patients with the combination of likely clinical probability of PE and normal D-dimer, PE was confirmed by baseline spiral CT scan in 7, and on follow-up in one other patient (). The results of this study validate the proposition that “clinical judgment continues to play a paramount role in patient care,” given the fact that, despite the introduction of new diagnostic tools and algorithms, during the period 1997–2006, in an institution with a 50.1% autopsy rate, the prevalence of misdiagnosis of fatal pulmonary embolism was second only to the prevalence of misdiagnosis of fatal myocardial infarction (). Accordingly, the most diagnostically advantageous way to optimize D-dimer test data might be to place greater reliance on likelihood ratios, as in the interpretation of serum ferritin results in suspected iron deficiency anemia, instead of dichotomizing the results into positive vs. negative (). The use of likelihood ratios to analyze data that have been presented in clinically sensible intervals also enhances the dialogue between clinically orientated researchers and their laboratory-based counterparts, so as to fine-tune diagnostic practice in the direction of better patient care.

The Impact of Emergency Department Overcrowding on Resident Education

2011-05-03

Abstract: Background: Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.Objectives: To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.Materials and Methods: A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann–Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.Results: During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7–10), compared to 8 (IQR 8–10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4–13.2), compared to 13.9 (95% CI 12.7–15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6–1.2), compared to 1.3 (95% CI 1–1.6) in group N (p = 0.047).Conclusions: During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.

A Standardized Code Blue Team Eliminates Variable Survival from In-hospital Cardiac Arrest

Sultana A. Qureshi, Terence Ahern, Ryan O’Shea, Lorien Hatch, Sean O. Henderson — 2011-02-28

Abstract: Background: Recent studies suggest that time of day affects survival from in-hospital cardiac arrest. Lower survival rates are observed during nights and on weekends, except in areas with consistent physician care, such as the Emergency Department. Since 1997, our hospital has utilized a standard, hospital-wide “Code Blue Team” (CBT) to respond to cardiac arrests at any time. This team is always led by an emergency physician, and includes specially trained nurses.Objective: To assess if time of day or week affects survival from in-hospital cardiac arrest when a trained, consistent, emergency physician-led CBT is implemented.Methods: This is an analysis of prospectively collected data on initial survival rates (return of spontaneous circulation >20 min) of all cardiac arrests that were managed by the CBT from 2000 to 2008. Cardiac arrests were also subcategorized based on initial cardiac rhythm. Survival rates were compared according to time of day or week.Results: A total of 1692 cardiac arrests were included. There was no significant difference in the overall rate of initial survival between day/evening vs. night hours (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.83–1.29), or between weekday vs. weekend hours (OR 1.10, 95% CI 0.85–1.38). This held true for all cardiac rhythms.Conclusion: At our institution, there is no significant difference in survival from cardiac arrest when a standardized “Code Blue Team” is utilized, regardless of the time of day or week.

An Intervention to Improve Compliance with Transmission Precautions for Influenza in the Emergency Department: Successes and Challenges

Larissa May, Derrick Lung, Katherine Harter — 2010-05-10

Abstract: Background: Concern with the potential for hospital-based transmission of influenza has come to the forefront due to emergency department (ED) crowding and the novel H1N1 pandemic. Compliance with infection control guidelines for influenza in the ED is generally unknown, and effective yet low-resource training is needed to educate staff on the importance of decreasing the potential for ED transmission of the virus. Objectives: This study evaluates compliance with patient assignment and transport precautions for influenza in an urban ED before and after implementation of electronic reminders. Methods: We included patients with a diagnosis of influenza for two consecutive influenza seasons, and retrospectively collected limited patient encounter data on patient location, transport, and compliance with assignment and transport precautions for both years. For the second influenza season we sent monthly reminders to all ED providers via the electronic medical record (EMR), explaining the importance and proper use of infection control precautions in patients with suspected influenza. Compliance between the two seasons was compared using descriptive statistics and chi-squared analysis. Results: Overall compliance with infection control precautions was poor, but increased with the use of electronic reminders from 29% to 45% (p = 0.015). Compliance with precautions for patients moved to the hallway or Radiology increased from 7% to 24% (p = 0.001). Conclusions: The EMR may be a useful tool for improving compliance with transmission-based precautions by implementing reminders on order sets and informational mailings, and by tracking compliance. Future study should be undertaken to determine the most effective interventions to prevent ED transmission of influenza.

American Academy of Emergency Medicine

2012-01-01

Rescuer Fatigue in the Elderly: Standard vs. Hands-only CPR

Joseph W. Heidenreich, Aleta Bonner, Arthur B. Sanders — 2010-07-16

Abstract: Background: Hands-only cardiopulmonary resuscitation (HO-CPR) is recommended as an alternative to standard CPR (STD-CPR). Studies have shown a degradation of adequate compressions with HO-CPR after 2min when performed by young, healthy medical students. Elderly rescuers' ability to maintain an adequate compression rate and depth until emergency medical services (EMS) arrives is unknown.Objectives: The specific aim of this study was to compare elderly rescuers' ability to maintain adequate compression rate and depth during HO-CPR and STD-CPR in a manikin model.Methods: In this prospective, randomized crossover study, 17 elderly volunteers performed both HO-CPR and STD-CPR, separated by at least 2 days, on a manikin model for 9min each. The primary endpoint was the number of adequate chest compressions (> 38mm) delivered per minute. Secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest.Results: There was no difference in the number of adequate compressions between groups in the first minute; however, the STD-CPR group delivered significantly more adequate chest compressions in minutes 2–9 (p<0.05). The total number of compressions delivered was significantly greater in the HO-CPR than STD-CPR group when considering the entire resuscitation period. A significantly greater number of rescuers took breaks for rest during HO-CPR than STD-CPR.Conclusions: Although HO-CPR resulted in a greater number of overall compressions than STD-CPR, STD-CPR resulted in a greater number of adequate compressions in all but the first minute of resuscitation.

Purchase and Use Patterns of Heroin Users at an Inner-city Emergency Department

2010-08-30

Abstract: Background: Many consider heroin abuse a problem of the inner city, but suburban patients may also be at risk.Objective: To characterize the demographics and purchase/use patterns of heroin users in an inner-city emergency department (ED).Methods: The study was conducted in one of the most impoverished and crime-ridden cities in the United States. Demographics and substance use habits of ED patients were prospectively collected. Patients who were<18 years of age, cognitively impaired, or did not speak English were excluded. Participants were further categorized as homeless, inner-city, and suburban residents.Results: Of 3947 participants, 608 (15%) used an illicit substance in the past year, with marijuana (9%) and cocaine (6%) the most commonly used. Heroin ranked third, used by 180 (5%) participants, with 61% male, 31% black, and 20% Hispanic. There were 64 homeless, 60 suburban, and 56 inner-city heroin users. The most common route of use was injection (68%), with the highest rate in the homeless (84%). The majority of homeless and inner-city users bought (73%, both groups) and used (homeless 74%, inner city 88%) in the inner city. Of suburban users, 58% purchased and 61% used heroin in the inner city. Prescription narcotic use was more common in homeless (20%) and suburban (23%) heroin users than in inner-city users (9%) (p<0.001).Conclusions: Heroin is the third most commonly used illicit substance by ED patients, and a significant amount of inner-city purchase and use activity is conducted by suburban heroin users.

Bedside Method to Estimate Actual Body Weight in the Emergency Department

2011-02-22

Abstract: Background: Actual body weight (ABW) is important for accurate drug dosing in emergency settings. Oftentimes, patients are unable to stand to be weighed accurately or clearly state their most recent weight.Objective: Develop a bedside method to estimate ABW using simple anthropometric measurements.Methods: Prospective, blinded, cross-sectional convenience sampling of adult Emergency Department (ED) patients. A multiple linear regression equation from Derivation Phase (n = 208: 121 males, 87 females) found abdominal and thigh circumferences (AC and TC) had the best fit and an inter-rater correlation of 0.99 and 0.96, respectively: Male ABW (kg) = −47.8 + 0.78 ∗ (AC) + 1.06 ∗ (TC); Female ABW = −40.2 + 0.47 ∗ (AC) + 1.30 ∗ (TC).Results: Derivation phase: Number of patients (%) with a body weight estimation (BWE) > 10 kg from ABW for males/females were: 7 (6%)/1 (1%) for Patients, 46 (38%)/28 (32%) for Doctors, 38 (31%)/24 (27%) for Nurses, 75 (62%)/43 (49%) for 70 kg/60 kg convention, and 14 (12%)/8 (9%) using the anthropometric regression model. For validation phase (55 males, 44 females): Gold standard ABW mean (SD) male/female = 83.6 kg (14.3)/71.5 kg (18.9) vs. anthropometric regression model = 86.3 kg (14.7)/73.3 kg (15.1). R2 = 0.89, p < 0.001. The number (%) for males/females with a BWE > 10 kg using the anthropometric regression model = 8 (15%)/11 (27%).Conclusions: For male patients, a regression model using supine thigh and abdominal circumference measurements seems to provide a useful and more accurate alternative to physician, nurse, or standard 70-kg male conventional estimates, but was less accurate for use in female patients.

Pulmonary Embolism in Pediatrics

Catherine Patocka, Joe Nemeth — 2011-04-29

Abstract: Background: Pulmonary embolism (PE), an uncommon diagnosis in pediatric patients, is a potentially life-threatening condition with significant morbidity and mortality. Improvements in pediatric care have resulted in survival of more chronically and critically ill children and thus, an increased number of pediatric patients at risk for this disease.Objectives: We review the pathophysiology, risk factors, presentation, diagnosis, and initial management of PE in pediatric patients presenting to the Emergency Department.Discussion: Although there is a significant lack of pediatric-specific literature pertaining to the diagnosis and management of PE, there are clear differences in the emergency approach to these patients, including specific risk factors and the inutility of clinical decision rules and D-dimer.Conclusion/Summary: We outline these differences and present rational diagnostic and treatment algorithms.

Gastrointestinal Emergencies

Sarah Winston — 2011-10-10

In the world of emergency medicine, the complaint of abdominal pain is frequent. Given the multitude of organs and potential culprits, the abdominal complaint can easily frustrate the clinician. Ideally, a simple but complete text comparing and contrasting the various etiologies and treatments for abdominal pain would exist. The gold standard for this is currently Cope’s Early Diagnosis of the Acute Abdomen, edited by William Silen . This is a difficult act to follow. Tham, Collins, and Soetikno sought to bring a fresh light to typical gastrointestinal issues.

Association of ICU or Hospital Admission with Unintentional Discontinuation of Medications for Chronic Diseases: Bell CM, Brener SS, Gunraj N, et al. JAMA 2011;306:840–7.

Mike Miller — 2012-01-01

In this population-based cohort study, Bell et al. examined the association between intensive care unit (ICU) or hospital admission with unintentional discontinuation of medications for chronic diseases. The study population included all hospitalized patients in Ontario, Canada from 1997 to 2009 who were 66 years of age or older and had at least 1 year of continuous medication use before hospitalization in at least one of the following five medication groups (n=187,912): 1) statins; 2) antiplatelet or anticoagulant agents; 3) levothyroxine; 4) respiratory inhalers; 5) gastric acid-suppressing medications. The control group consisted of non-hospitalized patients (n=208,468). The primary outcome was unintentional medication discontinuation, defined by failure to renew the prescription within 90 days. Rates of unintentional medication discontinuation were compared across three cohorts: patients admitted to the ICU, patients who were hospitalized without ICU admission, and non-hospitalized patients. The authors found that hospitalization was associated with an increased risk of medication discontinuation in all five medication groups, with adjusted odds ratios (OR) ranging from 1.18 (95% confidence interval [CI] 1.14–1.23) for the discontinuation of levothyroxine to 1.86 (95% CI 1.77–1.97) for the discontinuation of antiplatelet or anticoagulant agents. When compared to hospitalized patients without an ICU stay, those with admission to an ICU experienced a statistically significant increase in their risk of medication discontinuation in four of the five medication categories (all but the statins). Adjusted OR for medication discontinuation in those with an ICU admission ranged from 1.48 (95% CI 1.39–1.57) for the statins—representing 14.6% of ICU patients compared to 10.7% of controls—to 2.31 (95% CI 2.07–2.57) for the antiplatelets/anticoagulants—representing 22.8% of ICU patients compared to 11.8% of controls over the same time period. Secondary outcomes included death, emergency department visits, and emergent hospitalizations in the 1 year after medication discontinuation, and were found to be statistically significant among those who discontinued statins and antiplatelets/anticoagulants.

Early Stroke Risk and ABCD2 Score Performance in Tissue- vs Time-defined TIA: A Multicenter Study: Giles MF, Albers GW, Amarenco P, et al. Neurology 2011;77:1222–8.

Matt Taecker — 2012-01-01

Stroke risk after transient ischemic attack (TIA) is often prognosticated by scores such as ABCD2 to assist management and decision-making. Changing the definition of TIA and stroke from a time-based to a tissue-based diagnosis has been recently advocated by the American Stroke Association. This study investigated the performance of the ABDC2 prognostic tools in TIA sub-classified by imaging as tissue-positive (TP; stroke with rapid and complete recovery) or tissue-negative (TN; classic TIA) based on diffusion-weighted imaging (DWI) or computed tomography (CT) imaging according to newly proposed criteria. It involved 12 independent research centers at international locations that submitted data on cohorts of patients with a diagnosis of TIA (time based), which were categorized by ABCD2 scores, brain infarction, and outcomes of recurrent stroke at 7 and 90 days. Recurrent stroke was defined as a new neurologic deficit of vascular origin lasting more than 24h or leading to death and occurring after resolution of TIA. Those with minor strokes, a non-neurovascular diagnosis, and those who received imaging only after a recurrent stroke and not in the interval between TIA and stroke were excluded. Scores were calculated by investigators in face-to-face or telephone interviews or by record review, with images interpreted by study neurologists, radiologists, or reports from respective centers. A total of 4574 patients were included, of whom 3206 were imaged with DWI (27% had acute infarction) and 1368 imaged with CT (23.9% had infarction). DWI had pooled rates of stroke at 7 days of 7.1% (95% confidence interval [CI] 5.5–9.1) with TP events and 0.4% (95% CI 0.2–0.7%) with TN. CT had corresponding rates of 12.8% (95% CI 9.3–17.4) and 3% (95% CI 2.0–4.2). Analysis of predictive values of the ABCD2 score with an area under the receiver operator characteristic curve gave values at 7 days of TP 0.68 (95% CI 0.63–0.73) and TN 0.73 (95% CI 0.67–0.80). This suggests a correlation between the ABCD2 predictive rule and TP/TN events. Therefore, a TP scan with low ABCD2 score will have similar stroke risk as a TN scan with high ABCD2. This study is limited in that improved outcomes were shown in DWI (commonly available in specialist units), whereas CT tends to be used in emergency rooms and population-based cohorts. This potentially changes outcomes based on treatment effect and referral bias.

Risk of Constrictive Pericarditis after Acute Pericarditis: Imazio M, Brucato A, Maestroni S, et al. Circulation 2011;124:1270–5.

Lina Tran — 2012-01-01

This was a prospective cohort study out of Italy that aimed to evaluate the risk of developing constrictive pericarditis (CP) after acute pericarditis (AP) with a risk assessment according to the etiology. Five hundred cases of first-episode AP were clinically diagnosed by two of the following criteria: pericardial chest pain, pericardial friction rub, new diffuse ST-segment elevation or PR depressions, or new or worsening pericardial effusion. Cases were grouped based on the following etiologies: viral/idiopathic (n=416), connective tissue disease/pericardial injury syndromes (n=36), neoplastic (n=25), tuberculosis (n=20), and purulent (n=3); then prospectively followed for a median of 72 months to evaluate for progression to constrictive pericarditis. The study found that CP was a rare complication, with only 9 of the 500 cases of AP (1.8%) progressing to CP, with higher incidence in the non-viral/non-idiopathic group (n=7) when compared to the viral/idiopathic group (n=2). Incidences per 1000 person-years according to specific etiologies were as follows: viral/idiopathic 0.76, pericardial injury syndrome/connective tissue disease 4.40, neoplastic 6.33, tuberculosis 31.65, and purulent 52.74. The researchers concluded that the risk of developing CP after first-episode AP correlated with etiology, where bacterial causes were associated with the highest risk. Researchers also found that non-viral/non-idiopathic causes of AP were associated with higher rates of other adverse events during the follow-up period when compared to viral/idiopathic causes including: recurrent chest pain, recurrent pericarditis, and cardiac tamponade. Using bivariate analysis, the researchers also explored other potential risk factors for developing CP and found that the following features occurred in higher frequency in the 9 cases of CP when compared to patients who did not develop CP: fever>38°C (66.7% vs. 14.5%; p<0.001), incessant course (55.6% vs. 6.9%, p<0.001), large pericardial effusion (66.7% vs. 8.6%, p<0.001), cardiac tamponade (44.4% vs. 3.7%, p=0.002), and non-steroidal anti-inflammatory drug failure (66.7% vs. 18.7%, p=0.002).

Health Insurance Status, Medical Debt, and Their Impact on Access to Care in Arizona: Herman PM, Rissi JJ, Walsh ME. Am J Public Health 2011;101:1437–43.

Mike Miller — 2012-01-01

This study used data from the 2008 Arizona Health Survey to create logistic regression models examining how health insurance status affected medical debt and access to care among 2368 Arizona residents aged 18–64 years. Medical debt was defined as individuals who were having problems paying or were currently paying medical bills. Access to care was defined by delayed or missed medical care or medications due to cost or lack of insurance. The authors found that an individual's current insurance status was not an independent predictor of their medical debt. Importantly, however, individuals who had insurance at the time of the survey but were uninsured at some time during the preceding year (inconsistent coverage) had the highest measures of medical debt. These individuals had an adjusted odds ratio (AOR) of 2.48 for problems paying medical bills when compared to those with consistent coverage. A second important finding emphasized by the investigators was that medical debt is a better predictor of problems accessing care than is insurance status. In predicting delayed medical care, insurance status had an AOR=0.32, compared to an AOR=4.96 for problems paying medical bills and an AOR=3.04 for those currently paying off medical bills. Problems paying medical bills (AOR=6.16) and currently paying medical bills (AOR=3.68) predicted delayed medications.

Patients with Traumatic Brain Injury. Population-Based Study Suggests Increased Risk of Stroke: Chen YH, Kang JH, Lin, HC. Stroke 2011;42:2733–9.

Matt Taecker — 2012-01-01

Traumatic brain injury is devastating, incurring significant morbidity and mortality with sequelae of possible disease that may result from the injury: epilepsy, cognitive decline, psychiatric disorders, etc. Researchers in this study investigated the risk for stroke after traumatic brain injury (TBI), hypothesizing that damage to vasculature, formation of clots, increase in blood pressure, or utilization of antipsychotics as a result of the injury may lead to stroke in the time period after injury. The study was conducted in Taiwan via their National Health Insurance Program, which included 1,000,000 individuals randomly sampled from the registry of beneficiaries. Enrollment consisted of adults with first-time TBI without current or history of strokes, totaling 23,199 TBI patients. Cases were matched to three randomly chosen beneficiaries with similar characteristics of sex, age, and year of index. Total enrollments of 92,796 patients were followed for 5 years after index use of health care. Primary end point was use of ambulatory care, emergency medical services, or hospitalization for acute stroke. Mean age was 41.6 years; TBI patients were statistically more likely to have hypertension, diabetes, coronary artery disease, atrial fibrillation, or heart failure than those in the comparison cohort. Patient risk of stroke in TBI vs. non-TBI was 2.9% vs. 0.30% at 3 months, 4.17 vs. 0.96 at 1 year, and 8.20 vs. 3.89 at 5 years. After adjusting for confounders, a diagnosis of TBI was associated with hazard ratios (HR) for stroke of 10.21, 4.61, and 2.32 at 3-month, 1-year, and 5-year follow-up. Stratification revealed that risk of stroke was higher in patients with skull fractures than those without, HR at 19.98, 8.39, and 3.54, respectively, for the same time periods. Risk of subarachnoid and intracerebral hemorrhage increased more in patients with TBI than without, with adjusted HR for subarachnoid of 4.89 and intracerebral HR at 6.33. This study had limitations in that it could evaluate only those cases where patients sought treatment for TBI or stroke. In addition, this study did not have access to data on mechanism of TBI, and risk factors such as body mass index, diet, activity level, smoking, and alcohol consumption that may have altered the findings.

Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-tissue Infections: Williams DJ, Cooper WO, Kaltenbach LA, et al. Pediatrics 2011;128:479–87.

Lina Tran — 2012-01-01

This was a retrospective cohort study of 47,501 children aged 0–17 years comparing the effectiveness of treatment with trimethoprim-sulfamethoxazole (TMP-SMX) or a β-lactam vs. clindamycin in drained and undrained skin and soft-tissue infections (SSTI). Children with an SSTI and prescription for either clindamycin (reference treatment), trimethoprim-sulfamethoxazole, or a β-lactam (penicillin or cephalosporin) filled within 2 days of the SSTI were included in the study and grouped based on drainage status. Exclusion criteria included: SSTI within the last 365 days, treatment with multiple agents, treatment with topical antibiotics, SSTI requiring hospital admission, burns, foreign bodies, or surgical-site infections. Effectiveness of each antibiotic therapy was defined with respect to risk of treatment failure (SSTI within 14 days) or risk of recurrence (SSTI within 15 and 365 days of the initial SSTI). The study found 6407 children who underwent drainage, of which there were 568 (8.9%) treatment failures and 994 (22.8%) recurrences. The adjusted odds ratios (OR) for treatment failure with TMP-SMX and β-lactams were 1.92 (95% confidence interval [CI] 1.49–2.47) and 2.23 (95% CI 1.71–2.90), respectively, showing that the odds of treatment failure is nearly doubled with either antibiotic when compared to clindamycin. The risk of recurrence in the drainage group was also significantly higher with both TMP-SMX (adjusted hazard ratio [HR] 1.26; 95% CI 1.06–1.49) and β-lactams (adjusted HR 1.42; 95% CI 1.19–1.69) when compared to clindamycin. Of the 41,094 children without a drainage procedure, there were 2435 (5.9%) treatment failures and 5436 (18.2%) recurrences. The adjusted odds ratios for treatment failure were 1.67 (95% CI 1.44–1.95) for TMP-SMX and 1.22 (95% CI 1.06–1.44) for β-lactams. With respect to recurrences, the risk of recurrence in the group without drainage was significantly higher with TMP-SMX (adjusted HR 1.30; 95% CI 1.18–1.44) but not with β-lactams (adjusted HR 1.08; 95% CI 0.99–1.18) when compared to clindamycin. The researchers concluded that the use of TMP-SMX and β-lactams is associated with higher risk of treatment failure and recurrence when compared to clindamycin, especially in SSTIs where a drainage procedure is required, as these are commonly purulent SSTIs where community-acquired methicillin-resistant Staphylococcus aureus is likely the predominant organism. β-lactams, however, may still be effective in SSTIs not requiring drainage (non-purulent) as these are more commonly colonized by Streptococcus species, for which β-lactams and clindamycin show equal efficacy.

Predictors of Early and Late Case-fatality in a Nationwide Danish Study of 26,818 Patients with First-ever Ischemic Stroke: Andersen KK, Andersen ZJ, Olsen TS. Stroke 2011;42:2806–12.

Mike Miller — 2012-01-01

This study used data from the Danish National Indicator Project to retrospectively identify predictors of early case-fatality (3-day, 7-day, and 30-day) as well as late case-fatality (90-day and 1-year) in patients with first-ever ischemic stroke. It included 26,818 patients, all of whom were hospitalized for a first-ever ischemic stroke in Denmark between 2000 and 2007. Multiple logistic regression identified stroke severity (as defined by the Scandinavian Stroke Scale) and age as significant predictors of 3-day, 7-day, and 30-day case fatality. Interestingly, 3-day and 7-day case-fatality rates stabilized at ages>70 years, and the 3-day case fatality rates even declined at ages>85 years. The authors postulated that this may have been secondary to a “survival of the fittest” phenomenon where old age is associated with superiority in surviving disease. The only other variable identified as a significant predictor of early case-fatality was atrial fibrillation, which predicted 30-day case fatality with an odds ratio (OR) of 1.56. Predictors of late case-fatality included age and stroke severity, as well as atrial fibrillation (OR 1.37 at 90 days and 1.57 at 1 year) and diabetes (OR 1.35 at 90 days and 1.33 at 1 year). Additionally, previous myocardial infarction (OR 1.40), male gender (OR 1.28), and smoking (OR 1.21) were significantly associated with 1-year case fatality. Variables that were not significantly associated with case-fatality rates included hypertension, alcohol consumption, intermittent arterial claudication, and marital status.

Outcomes of Hospitalized Patients with Non-acute Coronary Syndrome and Elevated Cardiac Troponin Level: McFalls EO, Larson G, Johnson GR, et al. Am J Med 2011;124:630–5.

Matt Taecker — 2012-01-01

This study examined the outcomes of patients with elevated troponin levels but with non-acute coronary syndrome with data from 2006 from the Veterans Affairs (VA) centralized database. All patients seen during this year who had an elevated troponin during their index hospitalization were included and categorized as acute coronary syndrome (ACS) or non-acute coronary syndrome (non-ACS). Data for patients who died or who had a low expectation of survival based on discharges to hospice, skilled nursing/community nursing, or an inpatient stay>30 days were excluded, as they might not have been deemed eligible for cardiac imaging. Troponin results exceeding the 99th percentile of the upper reference limit for each hospitalization, medical center, and each quarter of the fiscal year were utilized as positive results. Researchers gathered hospital utilization data for 1 year after the reference hospitalization, identified patients who subsequently received cardiac imaging during hospitalization or within 90 days of reference hospitalization, then analyzed re-hospitalizations or death within 1 year. In 2006, 523,314 unique patients were admitted to the VA: 127,929 had troponin measurements, 95,840 patients remained after exclusion of deaths or low expectation of survival, 21,668 were troponin positive, 9268 were classified as ACS, and 12,400 as non-ACS. Non-ACS mortality at 1 year was 22.8%, compared to 17.5% for ACS (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.29–1.48). OR for death was 2.5 (95% CI 2.13–2.92) for non-ACS patients that did not receive cardiac imaging during hospitalization or within 90 days (OR 2.06; 95% CI 1.67–2.55). Among non-ACS patients, the most frequent diagnosis involved the cardiovascular system. Within that group, congestive heart failure and coronary artery disease were the most common clinical diagnoses. Specific therapies administered as a result of elevated markers and the rationale for not obtaining cardiac imaging are also not known.

Role of Conservative Management in Traumatic Aortic Injury: Comparison of Long-term Results of Conservative, Surgical, and Endovascular Treatment: Mosquera VX, Marini M, Lopez-Perez JM, et al. J Thorac Cardiovasc Surg 2011;142:614–21.

Lina Tran — 2012-01-01

Historically, the treatment of blunt traumatic aortic injury has been dichotomously defined by either open surgical repair and graft interposition or conservative medical management. However, the advent of endografting technologies over the past 10 years has yielded another option for the management of these rare but often devastating injuries. This study out of Spain is one of a few large single-center retrospective studies comparing the early and long-term outcomes of patients with acute traumatic aortic injury (ATAI) who were conservatively managed vs. those who underwent open surgical or endovascular repair. The 30-year study identified 66 patients with both minor ATAI (intramural hematoma without intimal tear or intimal tear<10mm) and major ATAI (transection or intimal tear>10mm or aneurysm/pseudoaneurysm) and divided them into three groups depending on treatment intention at the time of admission: conservative (n=37), surgical (n=22), and endovascular (n=7). The primary outcomes were in hospital mortality, late mortality (at 1, 5, and 10 years), and long-term survival free from aorta-related complications. The study found that overall in-hospital mortality was 18.2% and there was no statistically significant difference between the conservative group (21.6%), surgical group (22.7%), and the endovascular group (14.3%) (p=0.57). One hundred percent of all in-hospital aorta-related complications occurred in the conservative group (p<0.001). Kaplan-Meier estimates of long-term survival in all groups were: 81.2% at 1 year, 75.1% at 5 years, and 72.7% at 10 years. In the conservative group, survival was 75.6% at 1 year, 72.3% at 5 years, and 66.7% at 10 years; whereas in the surgical group, survival remained at 77.2% at 1, 5, and 10 years. The endovascular group's survival was 85.7% at 1 and 5 years (where 10-year follow-up was not yet available). There was an obvious trend toward both lower in-hospital mortality and higher long-term survival in the endovascular group when compared to the conservative or surgical group, however, neither proved to be statistically significant. Cumulative survival free from aorta-related complications (defined as complications requiring re-intervention or resulting in death) was recorded only for the conservative group and was as follows: 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. The results, however, were limited by statistically significant differences among the three groups, including age (significantly lower average age in the open surgical group) and type of aortic injury (significantly smaller proportion of major ATAI in the conservative group). Cox regression analysis identified two risk factors for the subsequent development of aorta-related complications: initial type of aortic lesion (hazard ratio [HR] 2.94; p=0.002) and Trauma Injury Severity Score of>50 (HR 1.49; p=0.042). The researchers concluded that although not statistically significant, the highest rate of aorta-related complications and highest overall mortality were found in the conservatively managed group, making conservative medical management safe only in a select number of patients, such as those with multiple severe associated injuries, in patients with high-risk comorbidities, or in minor ATAI. They go on to recommend that early endovascular repair be considered whenever possible in all ATAIs.

Development of a Screening Tool for Pediatric Sexual Assault May Reduce Emergency Department Visits: Floyed RL, Hirsh DA, Greenbaum VJ, Simon HK. Pediatrics 2011;128:221–6.

Mike Miller — 2012-01-01

This study retrospectively analyzed 163 cases of alleged sexual assault in children<12 years of age who presented to an Atlanta Emergency Department (ED) over a 2-year period. Investigators sought to define a screening tool that could accurately identify children who should receive their initial evaluation in a non-emergent setting. The screening tool consisted of the following four questions: 1) Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal contact? 2) Was genital or rectal pain, bleeding, discharge, or injury present? 3) Was there concern for the child's safety? 4) Was an unrelated emergency medical condition present? An affirmative response to any of these questions was considered a positive screen. Of the 163 cases that were evaluated, 90 (55%) had positive screens and 73 (45%) had negative screens. Patients were defined as being high risk if they had positive physical examination findings of anogenital trauma or infection, a change in custody, or an emergency medical condition. Fifty-six of the 163 cases were identified as high risk, and none of these patients had a negative screen. The sensitivity and negative predictive value of this four-question screening tool were both 100%. The specificity was 68% and the positive predictive value was 62%.

Heart Disease May be a Risk Factor for Pulmonary Embolism without Peripheral Deep Venous Thrombosis: Sørensen HT, Horvath-Puho E, Lash TL, et al. Circulation 2011;124:1435–41.

Matt Taecker — 2012-01-01

This study from Denmark sought to evaluate whether common heart diseases that increase the risk of left-sided arterial embolism (such as heart failure, myocardial infarction, atrial fibrillation, atrial flutter) are also associated with an increased incidence of isolated pulmonary embolism (embolism without an apparent peripheral venous source). This was a case-control study with data gathered over 27 years from 1980 to 2007 from the Danish National Patient Registry, totaling 109,752 patients with a first recorded incident of pulmonary embolism (PE) or deep vein thrombosis (DVT), or both, in the lower limb both as primary or secondary discharge diagnosis. For each case, a risk-set sampling was utilized to select five population controls matched to index patient's age, sex, and date of diagnosis, totaling 541,561 population controls. Confounders, such as preceding inpatient cancer, fractures, trauma, surgery, pregnancy, obesity, and psychiatric disease (considering this a marker for antipsychotic drug use, a risk factor for pulmonary embolism), were identified and utilized to classify as provoked vs. unprovoked thromboembolisms. Statistical analysis comparing the frequency and proportion of venous thromboembolism cases and controls were calculated within categories of demographic variables, heart disease history, and candidate cofounders generating associations using odds ratios (OR) with 95% confidence intervals (CI) to generate a rate ratio. Multiple outcomes combining PE and DVT were compared by utilizing estimated OR with adjustment for matching factors and covariants. Among the groups, 59,790 had a diagnosis of DVT only, 45,282 had PE only, and 4680 had a diagnosis of DVT with PE. All three case groups had a higher prevalence of previous hospitalizations for heart disease for all cases with unprovoked presentation, particularly if there was a heart disease hospitalization in the previous 3 months. Isolated PE was associated with acute myocardial infarction (MI) (OR 43.5; 95% CI 39.6–47.8) and heart failure admission (OR 32.4; 95% CI 29.8–35.2) in the 3 months before the index case, and right-sided valvular heart disease was noted to also confer increased risk over left-sided lesions (OR 13.5; 95% CI 11.3–16.1 vs. OR 74.6; 95% CI 28.4–105.8). ORs associated with MI and heart failure admissions in the 3 months before the index case were substantially lower for DVT and for DVT with PE than for isolated PE. Much of this association was driven by coincident hospitalizations for heart disease and by diagnosis of venous thromboembolism. If there was a hospitalization for heart disease 3 months before the index case, but no embolism was diagnosed during that hospitalization, then the relative risk estimates were lower; acute MI showed an OR for PE of 6.3 (95% CI 5.5–7.2), OR for PE and DVT 4.2 (95% CI 2.4–3.3), and OR for DVT alone 2.9 (95% CI 2.4–3.3). A hospital encounter for cardiac disease>3 months before PE or DVT was associated with only slightly elevated OR. The risk estimates were similar, but lower when subset analysis was conducted from the year 2000 onward to reflect increased diagnostic accuracy and shorter bed rest after MI. One limitation of this study is that often, a diagnosis of PE precludes further investigation for a concomitant DVT. If this rate of under-diagnosis is independent of preceding heart disease, and assuming that cardiac diagnoses of PE in combination with DVT are less than PE alone, then this would bias the study to favor isolated PE. Another limitation of the study is that data were obtained from a national database wherein 15–20% of patients may not have met strict clinical criteria for the diagnosis of DVT.

Calendar of Events

2012-01-01

Hypercapnic Coma Due to Spontaneous Pneumothorax: Case Report and Review of the Literature

2009-03-09

Abstract: Background: Hypercapnic coma is a rare differential diagnosis in the unconscious patient. One underlying mechanism may be hypoventilation due to spontaneous pneumothorax. Although hypercapnia is not a typical finding in spontaneous pneumothorax in patients with otherwise healthy lungs, under certain circumstances, hypercapnia may readily develop. Objectives: We report a rare case of profound hypercapnic coma due to spontaneous pneumothorax after contralateral pneumonectomy. In addition, we review other causes of hypercapnic coma and its outcome and discuss the relationship between arterial carbon dioxide partial pressure and level of consciousness. Case Report: An 85-year-old man without evidence of trauma or intoxication presented unconscious to our Emergency Department. The physical examination and X-ray study revealed a left-sided spontaneous pneumothorax. A right-sided pneumonectomy 25 years earlier had promoted the development of profound hypercapnic coma. After insertion of a thoracic drain, the coma rapidly resolved without any neurological deficit. Conclusions: Although severe hypercapnia is usually due to decompensation of chronic lung disease, pneumothorax potentially may cause hypercapnic coma. Review of the literature suggests that there is no close correlation between arterial pCO2 (partial pressure of CO2) levels and the degree of impairment of consciousness; however, levels exceeding 80 mm Hg are likely associated with significantly impaired consciousness. Hypercapnic coma usually resolves without neurological deficit as arterial pCO2 tensions decline.

Atrial Fibrillation from Thyroid Storm

Gabriel J. Martinez-Diaz, Carl Formaker, Renee Hsia — 2008-12-22

Abstract: Background: Thyroid storm is an often-discussed but rare presentation to emergency departments (EDs). The clinical presentation of a thyroid storm is the result of a hyperthyroid state that may result in significant morbidity or disability, or even death. Typically, patients are aware of their hyperthyroid condition, and may be able to recognize an episode of thyroid storm. However, the first presentation of hyperthyroidism could, in fact, be from thyrotoxic crisis. Objectives: To review the presentation of thyroid storm, including tachycardia, hyperpyrexia, agitation, and altered mental status, which can be easily misdiagnosed as drug intoxication. Case Report: We present the case of an otherwise healthy young adult who was sent to the ED by an outpatient care provider for generalized and vague symptoms of “feeling unwell” that was eventually diagnosed in the ED as thyrotoxic crisis. Conclusion: We use this case to emphasize that thyrotoxic crisis should be at least considered in the differential diagnosis of a patient with this presentation, and to highlight how, even with apparently usual and effective treatments, a patient may still decompensate.

Delayed Postpartum Hemorrhage Resulting From Uterine Artery Pseudoaneurysm Rupture

Soon Young Yun, Duk Hee Lee, Kwang Hyun Cho, Hyung Min Lee, Yoon Hee Choi — 2011-04-18

Abstract: Background: Rupture of a uterine artery pseudoaneurysm is an uncommon, but life-threatening, cause of postpartum hemorrhage. Cesarean delivery is the most common cause.Objectives: Prompt recognition and management are critical in severe vaginal bleeding. A diagnosis of pseudoaneurysm of the uterine artery can be established radiologically, such as with color Doppler ultrasonography and computed tomography. Angiography confirms the diagnosis. This condition can be treated with selective arterial embolization.Case Reports: We describe three cases of postpartum hemorrhage caused by rupture of pseudoaneurysms of the uterine artery after cesarean section.Conclusion: Uterine arterial pseudoaneurysm rupture is an infrequent, life-threatening cause of delayed postpartum hemorrhage requiring prompt diagnosis and treatment. Early crystalloid infusion and blood transfusion are essential. The initial management and stabilization of uterine artery pseudoaneurysm postpartum hemorrhage requires aggressive resuscitation. Arterial embolization should be considered the definitive treatment.

Calcific Tendinitis Mimicking Acute Prevertebral Abscess

Bharti Khurana — 2009-11-18

A 49-year-old woman presented to the Emergency Department (ED) with a 1-day history of worsening neck pain and inability to rotate the neck. The patient had awakened with neck stiffness that worsened throughout the course of the day, and was unable to sleep or turn her head during the night. She denied any fever, malaise, chills, or night sweats. The head and neck examinations showed mild posterior pharyngeal wall fullness and edema along the aryepiglottic folds. No lymphadenopathy was noted. All of the laboratory studies were unremarkable, with the exception of a slightly elevated erythrocyte sedimentation rate (31 mm per hour). Magnetic resonance imaging (MRI) of the neck revealed a prevertebral space fluid collection, raising concern for an abscess (). There was also a suggestion of calcification of the longus colli muscles near their insertion at C1, which was confirmed on a subsequent computed tomography (CT) scan (). The diagnosis of acute calcific tendinitis of the longus colli was made, and the patient was treated with non-steroidal anti-inflammatory drugs (NSAIDs) with significant clinical improvement within 4 days.

Isolated Post-traumatic Adrenal Hematoma: Detection by Bedside Ultrasound in the Emergency Department

Yen-Chang Huang, Wei-Jing Lee, Hung-Jung Lin, Po-Jen Yang — 2009-12-04

>A 34-year-old man without previous medical history was brought to the Emergency Department (ED) after being involved in a motorcycle crash. He sustained trauma to the right side of the abdomen. On examination, multiple abrasions were noted in the right upper abdomen and the patient complained of severe pain. Bedside ultrasound was performed upon the patient's arrival at the ED; it revealed a mass that was isoechogenic with the liver within the hepatorenal space (). Subsequently, a computed tomography (CT) scan was performed to determine the extent of the traumatic abdominal injury. The CT scan showed a 4.5 × 2.5-cm right-sided adrenal mass with an attenuation of 68 Hounsfield units, which was compatible with traumatic adrenal hematoma (). He was admitted to the hospital ward of the Urology Department for conservative treatment, and was discharged uneventfully after 4 days.

Metastatic Neuroblastoma: The Mimicker of Basilar Skull Fracture in Children

Antonio E. Muñiz — 2009-10-15

A 21-month-old Caucasian boy was seen at another hospital with a chief complaint of mild ecchymosis in the left infraorbital region. The parents denied any known trauma or fall. His examination did not reveal any obvious fracture and he was discharged with a presumed diagnosis of facial contusion from a fall. Three days later he presented with worsening ecchymosis and marked bilateral periorbital swelling.

Issue Highlights

2012-01-01

Partial Contents of Volume 42, Number 2

2012-01-01